RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-	-	2
BRANCH OF SERVICE:  ARMY	SEPARATION DATE: 20071220
SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “chronic left shoulder pain” with a disability rating of 0%.
CI CONTENTION: “The issues leading to my separation continue to be issues, 0% seems low…” The complete submission is at Exhibit A.
SCOPE OF REVIEW: The panel’s scope of review is defined in DoDI 6040.44. It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable. Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20070921	VARD - 20080708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lt Shoulder Pain	5099-5003	0%	Residuals, Lt Shoulder Fracture Repair	5203	10%	20071010	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Chronic (Non-Dominant) Left Shoulder Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered a left clavicular fracture that resulted in surgery (hardware fixation) in October 2004. He developed more severe and persistent left shoulder pain during a subsequent deployment to Iraq. Serial X-rays demonstrated intact hardware with normal alignment and no new fracture, nonunion, or malunion. Surgical hardware removal was discussed and reasonably declined.

Provider STR entries documented left shoulder sensory symptoms and subjective weakness, but no objective neurological findings other than hyperesthesia (oversensitivity to touch). There was grossly normal to modestly limited range of motion (ROM), with one physical therapy (PT) entry recording left shoulder flexion to 152 degrees and abduction to 130 degrees (both normal 180). There was no STR evidence of instability, impingement, or other VASRD-ratable findings. The 10 July 2007 MEB NARSUM examination, 5 months prior to separation, documented a complaint of mild-intermittent left shoulder pain especially with lifting and touching of left shoulder girdle. Physical examination recorded hyperesthesia over the clavicular surgical scar but no joint

tenderness, no note of instability or impingement, decreased strength (4/5) due to pain, and non- specific ROM limitation. The MEB NARSUM addendum documented left shoulder flexion to 150 degrees and abduction to 145 degrees, specifying painful motion.

At the 10 October 2007 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported nonspecific left shoulder pain with numbness and tingling over the clavicle and subjective weakness (denied subjective instability or impingement). Physical examination recorded clavicular hyperesthesia, positive impingement (Neer sign), and no note of instability or objective weakness. Left shoulder flexion and abduction were 120 degrees, and specified painful motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing painful motion and application of the U.S. Army Physical Disability Agency pain policy. The VA rated the left shoulder condition 10%, coded 5203 (clavicle or scapula, impairment), based on the C&P examination, citing nonunion without loose movement and painful motion. The VASRD
§4.71a threshold for rating shoulder ROM impairment (code 5201, limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), thus the evidence did not satisfy the minimum criteria. However, there was ample evidence for painful motion to support a 10% rating IAW VASRD §4.59. There was no instability or recurrent dislocation of the humerus to justify a higher rating under code 5202 (humerus, other impairment). A 10% rating under criteria of code 5203 (as above for the VA rating) requires concession of malunion or nonunion of the clavicular fracture, a criterion not established by the X-ray evidence. Members agreed, however, that code 5203 was otherwise a good clinical and analogous coding fit. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left shoulder condition coded 5299-5203.

BOARD FINDINGS: In the matter of the left shoulder condition, the panel recommends a disability rating of 10%, coded 5299-5203 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Fracture with Surgical Residuals	5299-5203	10%	

The following documentary evidence was considered:

2	PD-2017-05842

AR20200004367,

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY 251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

Dear	:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation. This will not result in any change to your separation document or the amount of severance pay. A copy of this decision will be filed with your Physical Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final. Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

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